SummaryWe describe a case of a 41-year-old woman with acute exacerbation of chronic thromboembolic pulmonary hypertension (CTEPH) complicated by rapidly progressive respiratory failure and right heart failure with cardiogenic shock. A computed tomography (CT) showed thrombi in the right main pulmonary artery and bilateral peripheral pulmonary arteries, and echocardiography showed right ventricular dilatation and tricuspid regurgitation, with an estimated pressure gradient of 80 mmHg. The patient was initially diagnosed with acute pulmonary thromboembolism, and thrombolytic therapy was administered. Her condition subsequently deteriorated, however, necessitating mechanical ventilation and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We performed emergency catheter-directed thrombectomy and thrombus aspiration. Pulmonary hypertension (PH) temporarily improved, but subsequently worsened, and the patient was diagnosed with CTEPH. Pulmonary endarterectomy (PEA) was performed. After PEA, we were unable to wean the patient off VA-ECMO, and rescue balloon pulmonary angioplasty (BPA) to the middle and inferior lobe branches of the right lung was performed. Five days after BPA, the patient was removed from VA-ECMO and on the 57th day of hospitalization, she was weaned off the ventilator. The patient was discharged after 139 days of hospitalization. Rescue BPA represents a useful intervention for improving PH and weaning off VA-ECMO in a patient with acute exacerbation of CTEPH. (Int Heart J 2015; 56: 116-120) Key words: Right heart failure, Pulmonary endarterectomy, BPA, ECMO, CTEPH C hronic thromboembolic pulmonary hypertension (CTEPH) is caused by organized pulmonary thrombosis, and is considered to progress, at least in part, from acute pulmonary thromboembolism, though the exact etiology remains unknown. Five-year survival rates in patients with a mean pulmonary artery pressure (PAP) less than 30 mmHg is approximately 90%; a mean PAP over 50 mmHg confers a survival rate of approximately 10%, and very poor prognosis.1) Pulmonary endarterectomy (PEA) in patients with CTEPH can markedly decrease PAP and improve prognosis. 2)In peripheral types of CTEPH, however, PEA is ineffective and associated mortality rates are high. Recently, the efficacy of balloon pulmonary angioplasty (BPA) in inoperable CTEPH patients was reported.3) We successfully employed BPA under veno-arterial extracorporeal membrane oxygenation (VA-EC-MO) in a patient with acute exacerbation of CTEPH that did not improve with PEA. Case ReportA 41-year-old woman presented at our hospital with dyspnea, edema, and weight gain. She had suffered from epilepsy since the age of 16, and at 36 had exhibited multiple lacunar infarctions on magnetic resonance imaging (MRI). She was a heavy smoker (40 cigarettes per day for 20 years), but had no family history of thromboembolic disease or blood coagulation disorders. She was taking phenytoin 100 mg tid, valproic acid 400 mg qid, and aspirin 100 mg sid.On admission, her blood pressure was 102/58 mmHg...
We designed a study to evaluate three factors (siphon gradient [PH], the right atrial pressure [RAP], and the inferior vena caval flow [IVCF]) to be optimized to maximize the venous drainage flow (DF) during partial cardiopulmonary bypass using eight venous cannulas of three different types and an original model circuit. The relationship between venous DF and the three factors is indicated by the multiple regression equation DF2 = alpha PH + beta RAP + gamma IVCF2 + C, where alpha, beta, and gamma are regression estimates and C is a constant. Multiple regression analysis results showed that DF was positively correlated with PH and RAP and negatively correlated with IVCF. A long cannula with 12 side holes and 60 cm long was considered to be useful to yield the optimal venous drainage flow under the condition of maintenance of the flow balance (DF and ICVF) and the pressure balance (RAP and IVCP) at the zero point. Moreover, this model may allow extensive research in flow dynamics of venous cannula without involving human subjects.
IntroductionAlthough thoracic endovascular aortic repair (TEVAR) has become a promising treatment for complicated acute type B dissection, its role in treating chronic post-dissection thoraco-abdominal aortic aneurysm (TAA) is still limited owing to persistent retrograde flow into the false lumen (FL) through abdominal or iliac re-entry tears.ReportA case of chronic post-dissection TAA treatment, in which a dilated descending FL ruptured into the left thorax, is described. The primary entry tear was closed by emergency TEVAR and multiple abdominal re-entries were closed by EVAR. In addition, major re-entries at the detached right renal artery and iliac bifurcation were closed using covered stents. To close re-entries as far as possible, EVAR was carried out using the chimney technique, and additional aortic extenders were placed above the coeliac artery. A few re-entries remained, but complete FL thrombosis of the rupture site was achieved. Follow-up computed tomography showed significant shrinkage of the FL.DiscussionIn treating post-dissection TAA, entry closure by TEVAR is sometimes insufficient, owing to persistent retrograde flow into the FL from abdominal or iliac re-entries. Adjunctive techniques are needed to close these distal re-entries to obtain complete FL exclusion, especially in rupture cases. Recently, encouraging results of complete coverage of the thoraco-abdominal aorta with fenestrated or branched endografts have been reported; however, the widespread employment of such techniques appears to be limited owing to technical difficulties. The present method with multiple re-entry closures using off the shelf and immediately available devices is an alternative for the endovascular treatment of post-dissection TAA, especially in the emergency setting.
The successful surgical repair of an uncommon case of blunt chest trauma is described. A 28-year-old man was involved in a motorcycle accident during which the victim struck a pole at high speed. Extracorporeal membrane oxygenation was required with a tentative diagnosis of traumatic respiratory distress syndrome, but he nevertheless continued to show progressive deterioration. In the preoperative evaluation, transesophageal echocardiography clearly demonstrated an injury involving of mitral regurgitation secondary to total rupture of a papillary muscle. Mitral valve replacement was performed seven days after the accident. The importance of the diagnostic process and surgical treatment are emphasised.
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